Get Appointed Step 1 of 3 33% NameThis field is for validation purposes and should be left unchanged.Applicant InformationAgency Name(Required)Year Agency Established(Required)Your First Name(Required)Your Last Name(Required)Your Title(Required)Phone Number(Required)Primary Email(Required)Agency WebsiteAddress(Required) Street Address City State ZIP California Agency License #(Required)Select all state(s) your agency is licensed in:(Required) AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY QuestionnaireWhat is your Agency National Producer Number (NPN)?(Required)Is your Agency/Brokerage a part of a Cluster?(Required) Yes No Provide the Cluster name:(Required)IronPeakISUPacWestPanoromaPIIBSmart ChoiceSIAAUVIS/RenaissanceIs your Agency/Brokerage currently, or has it ever been, appointed to another division at Baseline?(Required) Yes No Has your Agency/Brokerage license ever been suspended, revoked, or otherwise restricted by the Department of Insurance of ANY state?(Required) Yes No Has a carrier ever terminated your Agency/Brokerage appointment?(Required) Yes No Who was the Carrier and why?(Required) Have any of the principals, partners, officers, directors, or employees in your Agency/Brokerage ever been convicted in any state, federal, commonwealth, or territorial jurisdiction of felony crimes involving dishonesty or breach of trust, or any violation of Title 18 U.S.C. § 1033?(Required) Yes No Has your Agency/Brokerage filed bankruptcy in the last 7 years?(Required) Yes No Has your Agency/Brokerage had any Errors and Omissions claims in the last 5 years?(Required) Yes No Please provide a date and brief description:(Required)What is your Agency/Brokerage's total P&C premium volume?(Required)What is the total Workers’ Comp premium controlled by your Agency/Brokerage?(Required)Please select your Agency/Brokerage’s top 5 industry segments:(Required) Construction Healthcare Hospitality Automotive Car Dealers Manufacturing Transportation Agriculture Trucking Wholesale & Distribution How did you hear about us? Δ
